IN THE SUPERIOR COURT FOR THE STATE OF ALASKA

AT

In the Matter of the Change of Name for: )

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, ) CASE NO. CI

Petitioner (current legal name) )

) PETITION FOR CHANGE OF NAME

I, the petitioner, request the Court to enter judgment changing my name as follows:

1. My current legal name is

2.

3. The reasons for this request for a change of name are:

4. I seek this name change for personal reasons and not to avoid judgments, debts, obligations, or to defraud any person. The reasons stated are consistent with the public interest.

VERIFICATION

I state on oath or affirm that I have read this document and believe all statements made in it are true.

Date Petitioner’s Signature

Mailing Address City State ZIP

Daytime Phone

Subscribed and sworn to or affirmed before me at , Alaska

on .

(date)

(SEAL) Clerk of Court, Notary Public or other person

Authorized to administer oaths.

My commission expires